7074 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDEN IO PERMIT NUMBER
BUILDING FI TAPPLICATION & PERMIT
ADDRESS
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL7074
OWNERS PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
ti T wN
CONT AcrORs
NAME OUTLETS-SWITCHES-RECEP 5.00/1.00
LIC.NO. LIGHTING FIXTURES 5.00/1.00
ADDRESS oRs APPLIANCES-RESIDENTIAL 4.00
CONTRAS
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECTSIGN$ 6A0 PLAN CHECK FEE P,C.NO.
OR
ENGINEE
LIC.No SIGNS TRANS. 3.00
ADDRESS ENc' SPECIAL CIRCUIT t 5,01) PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
APPLI s/3c,7 S ��„2� MOTORS SEE FEE SCH. �{'
ADDRESS
�0.4� SERVICE CHANGE 10.00 /\/�/'(�(�JJ�/ J
00 LI 'IiNSlil1 CONTRACTORS DECLARATION
a U v I hereby affirm that I am licensed under provisions of Cllapter 9 ISSUANCE DATE
H rt w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r o z Professions Code,and my license is in full force and effect El ❑ ❑ ❑
z o - License Class Lic.Nun.ber
or Date Contractor
a u r BUILDING PERMIT
T,m m a OWMiR-BUILDER DECLARATION INFORMATION
Al0 AMISC.- REFER TO ORD
1 hereby affirm that I am exempt His...the Contractor's License VALUATION $/FT.
F u 0 4 Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00
se Code Any city or coumy which requires a permit to construct,alter, _
ce 2 Q Q improve,demolish,or repair any structure prior to its issuance,also ELEC.,CONTR. LIC.NO. ELEG '1
DLL requires the applicant for such permit to file a signed statement that TOTAL p/ PERMIT TO
a w ae he is licensed pursuant to tire provisions of the Contractor's License T
en Law(Chapter 9(cmumencingwith Section 7000)of Division 3 oftle -7�H ��C_.7
el : in.and P mfessions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE / �//❑.
r D the basis for the alleged exemption.Anyviolation of Section 7031.5 STORIES TYPE CONSTR.
i3� by any applicant li.rapem.it subjects the applicant Ina civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC GROUP RES.UNITS
their Sole compensation,will do the work,and the structure is not
intended or offered for.1e (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Cnntmctor's License Law docs not apply to an owner of
property who builds or ImpTOVCS Illereon,and who docs such work FIXTURES-PER TRAP 4.00 SO,FT.FLOOR AREA TOTALACREAGE
• himself or through his own employees,provided that such int prove-
mems arc not in tended or offered busule.11,howeveq tire building uilding GAS-EA.SYSTEM-11NC.40UTLETS 4.00
io intpmva an is sold within one year of completion,lire owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
Iu.vofor PrPo.aellfsale')' INDUSTRIAL WASTE INTER. 20.00 RES IND cOry PB Omer
liX��yT' 1,as owner of the property,ant exclusively contracting with ❑ ❑ ❑ ❑ ❑
.d contractors to Construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and professions Codc:'I'he Contractor's License Law does not apply
I.an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EFL) 1.00
contracts for such projects with a contractors)licensed pursuant to
the Contractors License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I wn ase, p old,SK_ /,B.&P.CAonthis WATER HEATER W/VENT ' 4.00
011
Ow-C .Dam WATER SYSTEM 4.00 ACC.DATE ACO.FILE NO.
WORKIiRS'COMP oNSAT1ON DECLARATION WATER TREATING EQUIP. 4-00
1 hereby affirm that 1 have a certificate ofconsent to self-insure ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.),
Policy No. Comp:ury
O' ❑ Certified copy is bcreby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy i, filed with the city inspection division. MISC- REFER TO ORD.
O Applicant Y [-] NI Y E:],, NEI
CC CER'IIFICA'1EDI7 EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOODZONE A,Cuc.
COMPENSATION INSURANCE PLG.CONTR. LAC.NO. PLG.
�
Z (Tsea
his idn read not be completed if the permit is for onTOTAL V
e ❑ NE] Y N- ❑ 01
hundred dollars 1$1the pe less.)'
LL O 1 iscertify
ued, It in lire re employ
of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
0 U mil is issued, I shall not employ any person in any manner so is to
U heconte subject to the Workers'Compensation laws of California.
a Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} to
NO['ICI i'1'0 APPLICANT': If,after making this Certificate of E.-
F_ Z_ enlption,you should become subject to the WorkeD,Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MCFA0 3.00
CONS'fRUCfION LENDING AGENCY AIR HANDLING UNIT(OVER 10000.EM.) 5.00 SEISMIC FEE
1 hereby affirm that there is a Construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATI NG UN IT(OV ER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and 'BOILER-COMP(3 H.P.or 100,000B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to rave, .indemnify and keep harmless the City o1' MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs a Id expens"which CONST.TAX
may in any way accrue gain 'id y in unsequence of tl PERMIT ISSUANCE 3.00
Jg,o ting Ot' 's permit MECH.CONT. LIC.NO. MECH.
TorALTOTAL
u reo opelican ontraclor V. -
INSPECTOR COPY